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Research AdministrationBiohazards and Lab Safety:
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Incident No. _______ THE MIRIAM HOSPITAL CHEMICAL SPILL INCIDENT REPORT SPILL LOCATION INFORMATION Date: _____ Day ____ Time _____ Bldg/Area _________________________ Building Floor _______________________ Room _____ Dept: ________________ Principal Investigator: ___________________________________________________ Person Initiating Notification: ___________________ Dept: _________________ Extension: _____________________________ CATEGORY SPILL INCIDENT ___ Minor Spill (Handled in-house by laboratory personnel or Safety personnel using spill kit) - Type of Chem/Material __________________________________ ____ Moderate Spill (requiring outside contractor-Clean Harbors) Type of Chem/Material ___________________________________________________________ Uncontrolled Spill (requiring Fire Department, RIDEM, or other agency notification) Type of Chem/Material _________________________________________________ Responding Agencies or Departments ______________________(use back of form for details if more space needed) Cause of Spill (explanation of incident): _______________________________________________________________ Hospital Employee(s) Responding to Spill: Name ________________________ Dept. ______________ Phone No. _________ Name ________________________ Dept. ______________ Phone No. _________ Name ________________________ Dept. ______________ Phone No. _________ SPILL CLEAN UP INFORMATION Person Conducting Cleanup Activities ___________________________________ Methods and Materials Utilized for Clean Up: ________________________________ Amount of Clean-UpWaste Generated ______________________________________ A copy of this report must be sent to TMH Safety Office. Please call X 3-5060 for pick-up of chemical spill material or ESD X32448 for CHEMO spill material removal. |
